Annual Wellness Visit (AWV)

HCPCS/CPT Codes

Frequency

  • G0438 - Once in a lifetime
  • G0439 and G0136 - Annually

Coverage

  • Beneficiary not within 12 months after effective date of their first Medicare Part B coverage period
  • Has not received Initial Preventive Physical Examination (IPPE) or AWV within past 12 months
  • Performed by health professional:
    • Physician
    • Physician assistant
    • Nurse practitioner
    • Clinical nurse specialist
    • Medical professional (including health educator, registered dietitian, nutrition professional or other licensed practitioner) or team of such medical professionals, working under direct supervision of physician

No specific diagnosis code required; bill using the most appropriate diagnosis

Payment

  • AWV copayment and deductible waived
  • G0136 copayment and deductible waived when:
    • Provided same day, by same provider, same claim as covered AWV
    • Billed with modifier 33 (Preventive Service)

Noridian Medicare Portal

Yes - G0438 and G0439

Billing Social Determinants of Health (SDoH) Risk Assessment

  • Implementation for SDOH Risk Assessment claims is January 1, 2024
  • CMS waives both coinsurance and deductible when it's:
    • Provided on same day as covered AWV
    • Provided by same provider as covered AWV
    • Billed with modifier 33 (Preventive Service)
    • Billed on same claim as AWV
  • Deductible and coinsurance applied when provided outside covered AWV

If we deny the AWV billed with SDOH Risk Assessment for exceeding the once-per-year limit, we’ll apply the deductible and coinsurance. We also apply the deductible and coinsurance when the SDOH Risk Assessment is delivered outside the covered AWV.

Resources

Last Updated Oct 08 , 2024